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What Are You Interested In?
(Please Select One)

Home Care Services

Employment Opportunities

Items marked with * are required.

Your Name:*

Phone:*

Is this a cell phone? Yes No

Email Address:*

Your Contact Preference:
Email Phone Text No Preference

Address:

City:

State: *

Zip Code:

What is your relationship to the person needing care?

When would you like services to begin? (Please select one)
Immediately Within 2 Weeks Within 4 Weeks Within 8 Weeks

Best to Contact During: *

How did you hear about us? *

ZIP Code where care is needed: *

Do you have an interest in receiving a Free In Home Care Consultation?
Yes No

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Additional Home Care Needs

Please complete the optional additional information form below.

Please select any services that you believe are required for your loved one: (Please select all that apply)

Homecare

Hospice Services

Homemaker / Household Services

Medication Reminders

Live In Homecare

Home Healthcare (Medical)

Companion Services

Meal Preparation

Home / Safety Monitoring

Assistance with Ambulation or Mobility

Transportation Non-Medical
(e.g. Errands, Shopping)

Personal Care
(e.g. Bathing, Dressing, Personal Hygiene)

Homecare for a Veteran or Surviving Spouse

When did the Veteran serve?

Did the Veteran serve over 90 days: Yes No

Please provide the following information about your loved one.

Gender: Age:

What, if any, existing medical conditions does your loved one have?

ALS

Incontinence

Alzheimer's / Dementia

Joint Replacement

Ambulatory Problems

Macular Degeneration / Low Vision

Arthritis

Other Eye Disorders & Diseases

Cancer

Osteoporosis

Colostomy

Parkinson's

Depression

Respiratory Disease

Diabetes

Stroke

Hearing Impaired

Surgical Recovery

Heart Disease

Disease or Condition Not Listed

Quadriplegic

None / Unsure

Which of the following best describes your loved one’s current living arrangement? (Please select one)

At home and living independently	Living with Family
At home with some services in place	Hospital or rehabilitation facility
Assisted living facility	Skilled Nursing Facility / Nursing Home

Do you need or want any of the following Consulting / Advisory Services? (Select all that apply)

Geriatric Care Management	Certified Senior Advisor
Legal / ElderLaw Services	Senior Financing Options (e.g., Reverse Mortgages, Life Settlements, etc.)

What funding source will you be using as the primary payer for the services? (Please select one)

Private pay	Long Term Care Insurance
Veterans Benefits

How much have you budgeted for these "out-of-pocket" expenses? (Please select one)

Less than $250 per week	$1,001 to $1,500 per week
$250 to $500 per week	Over $1,500 per week
$501 to $1,000 per week

Please indicate the number of hours of support services that you estimate your loved one will require. (Please select one)

4 hours/day a couple of times a week	Live in services
4 hours/day daily	24/7 services
Less than 4 hours/day	Just on the weekends
More than 4 hours/day

How would you describe your loved one's feelings about receiving assistance? (Please select one)

Very Receptive	Resistant to Help
No Preference	Somewhat Receptive
We have not discussed it yet

Please include any additional information that you think may be helpful.

Visiting Angels Living Assistance Services

To help us to better serve your home care needs, you can provide additional information about your loved one's needs.

Each Visiting Angels agency is a franchise that is independently owned and operated. The Franchisor, Living Assistance Services Inc., does not control or manage the day to day business operations of any Visiting Angels franchised agency.